International Journal for Equity in Health Biomed Central

International Journal for Equity in Health BioMed Central

Research Open Access Access to health care in relation to socioeconomic status in the Amazonian area of Peru Charlotte Kristiansson*1, Eduardo Gotuzzo2, Hugo Rodriguez3, Alessandro Bartoloni4, Marianne Strohmeyer4, Göran Tomson1 and Per Hartvig5

Address: 1IHCAR (Div International Health), Karolinska Institutet, Stockholm, Sweden, 2Inst Med Trop A von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru, 3Health Directorate of Loreto, Iquitos, Loreto, Peru, 4UFDID, University of Florence, Florence, Italy and 5Dept Pharmacology and Pharmacotherapy, Farma, University of Copenhagen, Denmark Email: Charlotte Kristiansson* - [email protected]; Eduardo Gotuzzo - [email protected]; Hugo Rodriguez - [email protected]; Alessandro Bartoloni - [email protected]; Marianne Strohmeyer - strohmeyerm@aou- careggi.toscana.it; Göran Tomson - [email protected]; Per Hartvig - [email protected] * Corresponding author

Published: 15 April 2009 Received: 22 April 2008 Accepted: 15 April 2009 International Journal for Equity in Health 2009, 8:11 doi:10.1186/1475-9276-8-11 This article is available from: http://www.equityhealthj.com/content/8/1/11 © 2009 Kristiansson et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract Background: Access to affordable health care is limited in many low and middle income countries and health systems are often inequitable, providing less health services to the poor who need it most. The aim of this study was to investigate health seeking behavior and utilization of drugs in relation to household socioeconomic status for children in two small Amazonian urban communities of Peru; Yurimaguas, Department of Loreto and Moyobamba, Department of San Martin, Peru. Methods: Cross-sectional study design included household interviews. Caregivers of 780 children aged 6–72 months in Yurimaguas and 793 children of the same age in Moyobamba were included in the study. Caregivers were interviewed on health care seeking strategies (public/private sectors; formal/informal providers), and medication for their children in relation to reported symptoms and socio-economic status. Self-reported symptoms were classified into illnesses based on the IMCI algorithm (Integrated Management of Childhood Ilness). Wealth was used as a proxy indicator for the economic status. Wealth values were generated by Principal Component Analysis using household assets and characteristics. Results: Significantly more caregivers from the least poor stratum consulted health professionals for cough/cold (p < 0.05: OR = 4.30) than the poorest stratum. The poorest stratum used fewer antibiotics for cough/cold and for cough/cold + diarrhoea (16%, 38%, respectively) than the least poor stratum (31%, 52%, respectively). For pneumonia and/or dysentery, the poorest used significantly fewer antibiotics (16%) than the least poor (80%). Conclusion: The poorest seek less care from health professionals for non-severe illnesses as well as for severe illnesses; and treatment with antibiotics is lacking for illnesses where it would be indicated. Caregivers frequently paid for health services as well as antibiotics, even though all children in the study qualified for free health care and medicines. The implementation of the Seguro Integral de Salud health insurance must be improved.

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Background Methods Following health reforms in the 1980s and 1990s, many Study area Latin-American countries moved from universal coverage Population and socioeconomic structure (free health care financed by public funds) towards cost This survey was conducted in 2002 in two Peruvian com- recovery initiatives utilizing, for example, user fees and munities, Yurimaguas (Department of Loreto) and Moy- social insurances [1-3]. However, user fees have been obamba (Department of San Martin). In 2002, each shown to represent an important barrier to accessing community had a population of approximately 32000 health services, especially for poor people[4]. Strategies inhabitants. Both departments represent one of the most including fee exemption – aimed at mitigating exclusion- underprivileged areas of Peru – the Amazonian region. ary effects – have proven to be stigmatizing and costly Approximately 55% of the population lives below the since administrational measures are needed to identify poverty line, and 15% in extreme poverty and the major- the poor [5,6]. It is likely, therefore, that if targeted inter- ity of the working population survive on subsistence farm- ventions are to be effective in reaching the poor, special ing [15]. Yurimaguas is less accessible than Moyobamba strategies need to be more carefully outlined [7,8]. which has a better infrastructure and is easily reached from the surrounding communities. In Peru, inequity in health service utilization during the late 1990s was shown for adults [9] but no corresponding Health services figures for children have been presented. This lack of The study was conducted in urban settings where geo- attention is surprising since death resulting from infec- graphical distances to health facilities are small. Yurim- tious disease remains a major health problem for children aguas has one Ministry of Health (MoH), a public in low and middle income countries. In Peru, the most hospital, a Local Committees for Health Administration common causes of mortality among children under five (CLAS) Maternal Health Centre [16] and two health posts. years of age remain acute respiratory tract infections [10]. In addition there is a Social Security Institute hospital (ES Furthermore, several studies have shown a well-estab- SALUD). In Moyobamba, there are three health posts and lished connection between socioeconomic status and one health center. At the time of the study, the hospital in health [11,12], where proximate factors, such as health Moyobamba belonged to ES SALUD system, and the MoH prevention, nutrition and care, have been directly linked facilities either paid the ES SALUD hospital for treatment to socioeconomic status [13]. These studies make clear of public sector patients or referred patients to the nearby that in addition to ill health, the costs for health care and city of Tarapoto. At both study locations, the hospital and medicines further impoverish vulnerable population health center employees mainly included medical doc- groups [14], poor children notwithstanding. tors, while the health posts were staffed exclusively with nurses, midwives and health technicians. The Seguro Integral de Salud state health insurance (SIS) was implemented in Peru in 2001 and at the time of this All licensed, private pharmacies – nine in Yurimaguas and study offered free of charge health care and pharmaceuti- fifteen in Moyobambas – had trained pharmacists on cals, such as antibiotics, to children in the study area, their staff list. However, in most cases, these pharmacies regardless of socioeconomic status. Access to health serv- were run by assistants without formal education. Offi- ices and pharmaceuticals following policy implementa- cially, antibiotics could only be sold by pharmacies, but in tion has improved, at least theoretically through the SIS, practice they were also bought without prescription, avail- for children from all socioeconomic groups; however, pre- able at the market place, in food stores or from traditional sumptive improvements in the health seeking behavior of healers. poor children have yet to be empirically analyzed or verified. The question of verifiable improvements becomes The SIS was created by merging the already existing Mater- even more essential when considering poor children who nal/Infant and School insurances. In theory, SIS provided have high geographic access to health facilities. The aim of health care and essential pharmaceuticals via the public this study, therefore, was to describe health care access – health care sector free of charge to those with low eco- measured as consultations with health professionals – nomic status, to pregnant women and to senior citizens, and antibiotic use in relation to socioeconomic status for according to insurance schemes specified by target group. children who recently presented symptoms of infectious In areas with a poverty level higher than 60%, such as the disease. Amazonian area, all children qualified for the insurance, irrespective of their parents' economic status. The insurance covered health care, including essential generic drugs and diagnostic services. Affiliation to the insurance was not, however, automatic and the children had to be regis- tered every calendar year at the hospital's SIS office.

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Means of data collection an open-ended question and then probed by stating all Design and sampling symptoms in the questionnaire one by one while also The results presented in this paper were generated within explaining the symptoms. the ANTRES project, a collaborative research project funded by the EC INCO-DEV, ICA4-CT-2001-1001, A system for checking data quality was developed in order addressing the themes of antimicrobial use and resistance to ensure high quality during study implementation: on a in Peru and Bolivia. daily basis, study supervisors screened the questionnaires for missing responses and logical inconsistencies and This cross sectional survey used household interviews. requested re-visits to households where more detailed Faecal samples were also collected for microbiological clarifications where needed. The caregivers were also studies, which have been reported elsewhere [17]. Chil- asked to show interviewers the package or blister pack if dren with three or more loose stools in the 24 hours prior antibiotic use was reported. If caregivers were not in pos- to sampling (WHO definition of diarrhoea, 1993) were session of the package or did not remember the name of excluded from the study in order to ensure the implemen- the antibiotic consumed, but could describe the package, tation of the microbiological study within the same sur- bottle or tablet, the interviewers presented them with vey. A modified cluster sampling approach was used and identifiable antibiotics samples. The interviewers also car- included a total of 1600 children, aged 6 to 72 months. ried a list of local antibiotic brand names and the corre- Eight hundred children from each village were sampled. sponding ATC category [18]. Yurimaguas and Moyobamba were divided into zones of varying sizes, containing households distributed in The health seeking behavior was classified into "self-care", blocks. A stratified sampling of blocks (within zones) was "exclusive consultation (with persons working with then conducted with a probability proportional to the size health issues)" and "self care and consultations". Self-care of the zone. Eighty clusters were sampled in each commu- was defined in line with Levin [19] as all those activities nity, with each cluster consisting of 10 children (one per undertaken to treat illness without professional assist- household) within a randomly assigned block. Within ance. We defined medical doctors, nurses and midwives, each block, the interviewers randomly chose a corner of health technicians, pharmacy staff and traditional healers the block and, pursuing a random direction from this cor- as professional assistance or, as stated in the question- ner, consecutively visited households until they had naire, "persons working with health issues". recruited ten eligible children. If they found no child aged 6 to 72 months, the interviewers proceeded to the next Illness classification house, and likewise, if no eligible child was identified The symptoms (as reported by caregivers) were classified within a block, the interviewers proceeded to a nearby according to the principles of the IMCI algorithm (Inte- block, which had been mapped as a substitute. In total, grated Management of Childhood Illness) for classifica- 780 children from Yurimaguas and 793 children from tion and treatment of infectious diseases in children in Moyobamba were included in the study described in this low malaria-prevalence areas [20]. The algorithm is based paper. on the absence or presence of the following key symptoms: fast breathing, cough, diarrhoea, and/or blood in Interviews stool. Household interviews were conducted by ten trained interviewers from the public health sector (health techni- The children were classified with one of the following ill- cians, nurses or midwives) who had extensive experience nesses: diarrhoea (presence of: diarrhoea; absence of: working with community outreach activities. The chil- blood in stool, cough and other symptoms of cold, 'fast dren's caregivers (mother, father, grandparent or other breathing'), dysentery (presence of: blood in stool, adult caregiver) were interviewed using a structured ques- diarrhea; absence of: cough and other symptoms of cold, tionnaire (available from the first author) which had been 'fast breathing'), cough/cold (presence of: fever, cough pre-tested and validated during a pilot study. The caregiv- and other symptoms of cold; absence of: diarrhoea, blood ers were chosen for the interviews on the basis of being in stool, 'fast breathing'), pneumonia (presence of: 'fast present in the household and taking care of the child dur- breathing', cough; absence of: diarrhoea, blood in stool), ing the time of the interviewers' visit. The majority of car- cough/cold + diarrhoea (Symptoms of cough/cold and egivers were mothers (87% in Moyobamba and 85% in symptoms of diarrhea), pneumonia and/or dysentery Yurimaguas). Interview questions addressed the child's (one of following three combinations: symptoms of symptoms for the most recent illness during the previous pneumonia and diarrhoea, or symptoms of pneumonia two weeks, as well as all actions taken by the caregivers to and dysentery, or cough/cold and dysentery). cure the symptoms, including medication and healing practices. The interviewers first asked for the symptoms in

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Analysis of wealth status Results In many low-income settings, it is problematic to use tra- Morbidity ditional measures, such as income or consumption, for Of a total of 780 children from Yurimaguas included in the assessment of an individual's financial status, due to the study, 382 (48%) children had shown symptoms practical limitations of collecting accurate data [12]. In related to infectious illnesses in the previous two weeks. In this study, wealth was used as a proxy indicator for the Moyobamba, 425 (54%) of a total of 793 children had economic status, under the assumption that wealth is suffered from symptoms. In total, four children were reflected in the assets owned within a household [21]. excluded due to incomplete data regarding health seeking Information about household assets and characteristics behavior, leaving 803 children for further analysis. was collected during the interviews. Principal component analysis (PCA) was used to generate scoring weights for Health seeking behavior each variable: the number of household members divided Many caregivers (42%) stated that they had consulted by the number of rooms in the house, the access to elec- health professionals with regard to their children's health tricity, type of floor, type of toilet, type of water source, problems (Table 1). The least poor households had con- and the ownership of a fan, TV, motor-bike and refrigera- sulted health professionals for the non-severe illness tor, using the first principal component. The scores were cough/cold significantly more frequently than the poorest then summed up to assign a wealth index value to each households (p < 0.05: OR 4.30). Similarly, for the non- household. The consistency of the PCA-assigned wealth severe illness, cough/cold + diarrhoea, least poor house- with the ownership of assets was controlled by cross tab- holds had consulted health professionals to a greater ulations. No absolute cut-off points for the level of wealth extent (p < 0.05: OR 3.74). The least poor households also could be assumed based on the wealth index values. Thus, consulted more frequently with health professionals for the population was divided into quartiles based on the severe illnesses, such as pneumonia and/or dysentery (OR value of the wealth variable in order to capture relative = 2.33) and pneumonia (OR = 2.92), even though the dif- variances. For the analysis presented in this paper, quartile ference was not significant. number one (Q1) was considered as a proxy for the lowest wealth – the poorest, and quartile number four (Q4) as In all strata, public sector medical doctors were the most the least poor – the richest. commonly visited health professionals. The least poor households consulted nurses and health technicians to a Data analysis lower extent (1% and 1%, respectively) than the poorest The data from the questionnaires was introduced into an households (12% and 24%, respectively). Caregivers from EPI INFO 2000 [22] database by double-entry and then all strata paid out-of-pocket for care provided by public compared. All discrepancies were verified with the paper sector health facilities (Table 2). In Yurimaguas, signifi- originals and corrected. The database was exported to cantly more caregivers from the two least poor strata made STATA, where it was scrutinised for quality and consist- out of pocket payments, as compared to the two poorest ency prior to data analysis. Wealth variables were created strata (p < 0.05). Also in Moyobamba more least poor car- separately for the data sets from Yurimaguas and Moy- egivers made out of pocket payments, but the difference obamba by using the PCA. The respective wealth quarters between strata was not significant. from each community were then pooled to provide a data set large enough to allow for statistical analysis of varia- Use of antibiotics bles related to health seeking behavior and use of medi- A similar antibiotic use was reported for the children in cines. The poorest quarter consisted of Q1 from Yurimaguas and Moyobamba (42% and 36% respec- Yurimaguas and Q1 from Moyobamba, and so forth. tively). As the patterns of medicine use in relation to socio-economic status and illnesses were similar for the The relation between wealth and health seeking behavior two communities, the pooled data from both is presented and antibiotic use was assessed. Logistic regressions were in Table 3. For cough/cold, the least poor used signifi- used to analyze differences between strata. Chi-square cantly more antibiotics than the poorest (OR = 2.29). The tests have been used to assess differences between the same trend could be observed for pneumonia and/or dys- poorest half of the population (the two poorest strata entery, with the least poor using significantly more antibi- pooled together) and the least poor half (the two least otics (80%) than the poorest (16%). poor strata pooled) in relation to cost incurred for health care, cost for antibiotics and place of provision of antibi- Location of antibiotic acquisition otics. The difference has been considered significant if the The locations for antibiotic provision, including antibiot- p-value is less than 0.05. ics for self-medication, were investigated. In Yurimaguas, the two least poor strata had bought their antibiotics (either as a part of self care or with a prescription) at the

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Table 1: Children seeking care from health professionals in relation to self reported symptoms and wealth quarters

Children seeking care from health professionals

Illness Q1 Q2 OR Q3 OR Q4 OR % seeking care % seeking care % seeking care % seeking care (total no children with (total no children with (total no children with (total no children with illness) illness) illness) illness)

Cough/cold 21% (99) 28% (116) 1.62 28% (128) 1.88* 51% (104) 4.30* Pneumonia 33% (12) 82%(11) 5.25 50% (16) 1.94 71% (14) 2.92 Cough/cold + 35% (62) 46% (46) 1.70 41% (37) 1.62 50% (30) 3.74* diarrhoea Pneumonia and/ 50% (18) 54% (13) 1.17 67% (9) 2 70% (10) 2.33 or dysentery Diarrhoea 17% (18) 27% (22) 1.05 40% (10) 1.87 20% (15) 0.93

Total 209 208 200 173

Self reported symptoms classified as illnesses based on principals from IMCI. Wealth quarters were defined by principal component analysis (PCA). Quartile 1 (Q1) represents the poorest quartile of the study sample (the relatively poorest caregivers), quartile 2 (Q2) the second poorest, quartile 3 (Q3) the second least poor quartile and quarter 4 (Q4) the least poor quartile. Amount of children seeking care from health professionals (pharmacy staff not included) is showed as percentage and total number in parenthesis. OR = Odds ratio. The Odds ratio is stated for each wealth quarter as compared to quarter 1. * = p < 0.05 pharmacy (private or public pharmacy) significantly (p < obamba, there was no significant difference between 0.05) more frequently (45%) than the two poorest quar- strata. tiles (15%) (Table 4). The least poor group received their antibiotics free of charge by the health insurance system Discussion (40%) less frequently than the poorest quartile (65%). In This study shows that the poorest households consulted Moyobamba, the least poor caregivers more frequently health professionals for their sick children less frequently. (58%) received antibiotics free of charge from the insur- The poorest children were provided with fewer antibiotics ances than the poorest group (46%). for illnesses where the IMCI algorithm recommended antibiotic use. Inequity in access to health care, here meas- The cost associated with antibiotics prescribed by public ured as consultations with health professionals, prevailed sector health professionals was investigated. In Yurim- in an urban setting despite of high geographical access to aguas, the two least poor strata had made out-of-pocket health facilities and the SIS health insurance providing payment for the antibiotics to a significantly larger extent free health care to children. The high theoretical access to (p < 0.05) than the two poorest strata (Table 5). In Moy- health care makes this study unique from other studies

Table 2: Cost incurred for public sector health care

Cost incurred for public sector health care

Yurimaguas Moyobamba Free of charge Paid out-of-pocket Total Free of charge Paid out-of-pocket Total

Poorest (Q1) 31 (86%) 5 (14%) 36 13 (87%) 2 (13%) 15 Q2 48 (92%) 4 (8%) 52 24 (92%) 2 (8%) 26 Q3 29 (74%) 10 (26%) 39 25 (81%) 6 (19%) 31 Least poor (Q4) 26 (67%) 13 (33%) 39 34 (81%) 8 (19%) 42

134 32 166 128 30 158

Number of caregivers paying for the health care provided by the public sector health professionals stated in relation to wealth quartiles (as defined by principal component analysis (PCA)). Quartile 1 (Q1) represents the poorest quartile of the study sample (relatively poorest), quartile 2 (Q2) the second poorest, quartile 3 (Q3) the second least poor quartile and quarter 4 (Q4) the least poor quartile. Number of children whose caregivers paid for the health care provided by the public sector health professional or who were provided care free of charge, stated as numbers, with percentage of total number of children per quartile indicated in parentheses. Chi-square tests have been used to assess differences between two poorest (Q1 and Q2) and two least poor (Q3 and Q4) strata. Significant difference between strata was found for Yurimaguas (p < 0.05) but not for Moyobamba.

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Table 3: Antibiotic use in relation to self reported symptoms and wealth quarters

Use of antibiotics

Illness Q1 Q2 OR Q3 OR Q4 OR % using antibiotics % using antibiotics % using antibiotics % using antibiotics (total no children with (total no children with (total no children with (total no children with illness) illness) illness) illness)

Cough/cold 16% (99) 30% (116) 1.85 39% (128) 2.17* 34% (104) 2.29* Pneumonia 64% (12) 63%(11) 0.93 56% (16) 0.71 53% (14) 0.63 Cough/cold + 38% (62) 62% (46) 2.64* 47% (37) 1.41 52% (30) 1.73 diarrhoea Pneumonia 16% (18) 80% (13) 21.33* 70% (9) 12.44* 80% (10) 21.33* and/or dysentery Diarrhoea 35% (18) 43% (22) 1.39 -(10) - 39% (15) 0.93

Total 209 208 200 173

Self reported symptoms were classified as illnesses based on principals from IMCI. Wealth quartiles were defined by principal component analysis (PCA). Quartile 1 (Q1) represents the poorest quartile of the study sample (the relatively poorest of the caregivers), quartile 2 (Q2) the second poorest, quartile 3 (Q3) the second least poor quartile and quarter 4 (Q4) the least poor quartile. Amount of children treated with antibiotics, including through self medication, showed in percentage, total number of children shown in parentheses. OR = Odds ratio showing each wealth quarter as compared to quarter 1. * = p < 0.05 focusing on Latin American countries where similar ineq- lowing initiation of the SIS, it is plausible that caregivers uitable results have been shown [9,23]. lacked adequate information about the benefits and regu- lations of the new SIS insurance system or that they may During the study period, the recently introduced Peruvian have confused it with previous insurance schemes that state health insurance Seguro Integral de Salud (SIS) were granted only after assessment of the families' finan- aimed to reduce financial barriers to health by providing cial status. Either way, during the implementation of this free health care and pharmaceuticals for the target groups. study, the local health professionals complained that the In the Amazonian area, all children qualified for the SIS poorest households were "over-seeking" health care for due to the high poverty status of the region. However, the unnecessary symptoms and thereby wasting resources. formal supply of free health care was not enough to Ironically, this attitude would have contributed to pre- ensure equitable access, and instead, remaining barriers venting truly vulnerable patient groups from seeking exist which prevented equitable supply. For example, fol- health care. Moreover, caregivers' perceptions about qual-

Table 4: Place of acquisition of antibiotics in relation to wealth quarters

Place of antibiotic acquisition in Yurimaguas Place of antibiotic acquisition in Moyobamba

Public Private Market Free of Other Total Public Private Market Free of Other Total pharmacy pharmacy place charge pharmacy pharmacy place charge through through insurance insurance

Poorest 2(6%) 3 (9%) 5 (15%) 22 (65%) - 32 8 (29%) 5 (18%) 1 (4%) 13 (46%) 1 (4%) 28 (Q1) Q2 5 (10%) 7 (14%) 3 (6%) 33 (66%) 1 (2%) 49 3 (7%) 15 (38%) 4 (10%) 17(43%) 1 (3%) 40 Q3 7 (19%) 11 (31%) 1 (3%) 15(42%) 1 (3%) 35 7 (17%) 12 (29%) 2 (5%) 19 (45%) 2 (4%) 42 Least 9 (24%) 8 (21%) 1 (3%) 19 (40%) 1 (3%) 38 10 (25%) 5 (13%) - 23 (58%) 2 (6%) 40 poor (Q4)

Total 23 29 10 89 3 154 28 37 7 72 6 150

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Table 5: Type of financing for antibiotics prescribed by public sector health professionals, in relation to wealth quarters

Financing for antibiotics prescribed by public sector

Yurimaguas Moyobamba Free of charge Paid Out-of-pocket Total Free of charge Paid Out-of-pocket Total

Poorest (Q1) 21 (91%) 2 (9%) 23 12 (86%) 2 (14%) 14 Q2 33 (92%) 3 (8%) 36 18 (100%) - 18 Q3 15 (75%) 5 (25%) 20 15 (71%) 6 (29%) 21 Least poor (Q4) 15 (54%) 13 (46%) 28 18 (72%) 7 (28%) 25

84 23 107 63 15 78

Wealth quarters were defined by principal component analysis (PCA). Quartile 1 (Q1) represents the poorest quartile of the study sample (the relatively poorest caregivers), quartile 2 (Q2) the second poorest, quartile 3 (Q3) the second lest poor quartile and quarter 4 (Q4) the least poor quartile. Number of children receiving antibiotics prescribed by public sector health professionals provided free-of-charge or in return for out-of- pocket payment stated as numbers, with percentage per quartile and community shown in parentheses. Chi-square tests have been used to assess differences between two poorest (Q1 and Q2) and two least poor (Q3 and Q4) strata. Significant difference between strata was found for Yurimaguas (p < 0.05) but not for Moyobamba. ity of care and pharmaceuticals, as well as attitudes of heath-seeking behavior. An analysis of the costs paid for health professionals, have been shown to be important the antibiotics and the health care provided by public sec- factors determining health facility utilization [24-27]. tor health professionals showed that a number of caregivers had paid for their antibiotics, even though these were The analysis of costs associated with health care services supposed to be provided free of charge to all children provided by the public health facilities in the two study through the SIS insurance. Our assessment of the location sites showed that payments were made for consultations where the antibiotics had been acquired showed that a with health professionals, more often in Yurimaguas than large part of the antibiotics were bought at public pharma- in Moyobamba. Cost has been shown to be an important cies. This finding indicates that the SIS implementation factor influencing health seeking behavior [28]. According was not functioning in an optimal manner, as the health to information from key informants, as well as the first facilities were still charging the patients. On the other author's own observations, health facilities in several hand, purchasing antibiotics rather than receiving them regions of Peru excluded, based on cost, some aspects of free of charge could also be an indication of problems treatment from the SIS benefits, such as diagnostic serv- related to out-of-stock pharmaceuticals in the public sec- ices, or limited the amount of beneficiaries per day. Reim- tor or that informal payments were charged. bursement procedures were also too unclear and facilities feared losing money on the SIS patients. Instead, the The poorest were mainly self caring for non-severe ill- patients had to pay services out-of-pocket, which could nesses such as common cold or non-complicated have caused the poorest group to avoid seeking care rather diarrhea. This is in line with IMCI recommendations [20] than facing the risk of unexpected costs. The difference in and can be considered as rational. In contrast, the least cost charges between Yurimaguas and Moyobamba could poor frequently sought health care for the same illnesses have been the result of the respective communities' inter- where consultations were not really necessary. By doing pretation and implementation of the SIS insurance and its this, they also contributed to a waste of financial resources benefits at the health facility level. Another important bar- allocated to health care services. Of note, the least poor rier at this level is the time consuming nature of adminis- children were also frequently given antibiotics for ill- trational procedures as related to SIS affiliation. It is nesses where it was not indicated according to the IMCI further possible that people chose to pay for care rather guidelines. This trend coincided to their frequent health than losing valuable hours waiting in line at the SIS office. care consultations, as the majority of antibiotics were pre- The influence of similar health systems constrains on scribed by the health professionals. effective service delivery and health seeking behavior has been underlined by other researchers [29]. Conclusion This study shows that even in a setting providing universal The poorest children were provided with fewer antibiotics access to free health care for children, the poorest seek less for some of the illnesses where antibiotic use was recom- care from health professionals for severe illnesses, and mended in the IMCI algorithm. According to our defini- that treatment with antibiotics is lacking for illnesses tion, this disadvantage represents a link to the inequity in where it should otherwise be indicated. Despite that all

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children in the study qualified for free health care and 9. Valdivia M: Public health infrastructure and equity in the utilization of outpatient health care services in Peru. Health Policy medicines, their caregivers frequently paid for health serv- Plan 2002, 17(Suppl):12-19. ices as well as antibiotics. Given these findings, the imple- 10. PAHO: Health in the Americas 2007, Volumes I and II. PAHO mentation of the Seguro Integral de Salud health Scientific Publication, No 622; 2007. 11. Marmot M, Wilkinson R: Social Determinants of Health. 2nd insurance must be improved. edition. Oxford: Oxford University Press; 2006. 12. Gwatkin DR: Health inequalities and the health of the poor: what do we know? What can we do? Bull World Health Organ Competing interests 2000, 78(1):3-18. The authors declare that they have no competing interests. 13. Wagstaff A: Poverty and health sector inequalities. Bull World Health Organ 2002, 80(2):97-105. 14. Whitehead M, Dahlgren G, Evans T: Equity and health sector Authors' contributions reforms: can low-income countries escape the medical pov- CK participated in the design and implementation of the erty trap? Lancet 2001, 358(9284):833-836. study, acquisition of data, analysis and interpretation of 15. Encuesta nacional de hogares, anual Mayo 2003 – Abril 2004 2004 [http://www.inei.gob.pe/]. data and helped to draft the manuscript. EG participated 16. Iwami M, Petchey R: A CLAS act? Community-based organiza- in the design and coordination of the study, analysis and tions, health service decentralization and primary care development in Peru. Local Committees for Health Admin- interpretation of data and helped to draft the manuscript. istration. J Public Health Med 2002, 24(4):246-251. HR, AB and MS participated in the design and implemen- 17. 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